The Quality and Outcomes Framework: what have you done to yourselves?

what have you done to yourselves? gain, we risk further losing our professional identity and reputation. More importantly, the very presence of the framework is deeply corrosive to the ethical practice of medicine. What were you thinking? To quote one UK GP: 'The profession has essentially been bribed to implement a population-based disease management programme that often conflicts with the individual patient-centred ethos of general practice.' 3 The QOF incentivises (coerces) GPs, in turn, to persuade patients. Payments equate to 20% of NHS income (over £1 billion in total per annum). 4 What starts as an incentive becomes coercion when it represents such a large proportion of practice income that its loss becomes a credible threat. 5 The intended outcomes are explicit; the unintended consequences are worrisome, unknown and, in many instances, unmeasurable. The costs in the short and long term include loss of respect for the autonomy of doctors and patients, loss of critical thinking, de-professionalization, and ultimately demotivation with a loss of core values. Robin Downie has described the characteristics of a profession that underpin good care: a credible profession must be independent of the influence of the state or commerce; disciplined by its own professional association; have claim to and be actively expanding its unique knowledge base; and concerned with the education of its members. 6 Professional relationships and attitudes are special and require a combination of beneficence and integrity. If a profession is widely recognised as satisfying these conditions, then it will have moral and legal legitimacy, and its pronouncements will be listened to with respect. 6 The progressive loss of independence to external influence is central to the de-professionalization inherent in the QOF. The medical profession is already struggling to disentangle itself from the influence of the pharmaceutical industry, and now faces increasing, unwanted, and often unrecognised influence from the state. Both threaten its independence. It has become unfashionable to talk of compliance in the framework of the doctor–patient relationship. 7 However, the notion of compliance has now moved up a level — one step removed from the patient — to include state-determined definition and micromanagement of what constitutes good care in general practice. The QOF payments amount to up to £42 000 per GP, with an average increase of £23 000 in the 2004–2005 year. 4,8 At this level, payments introduce a significant conflict of interest which arguably is no different, in principle, to …